Conservative versus surgical management of placenta accreta spectrum following mid-trimester abortion: a case series

Abstract

Placenta accreta spectrum (PAS) is a rare but potentially life-threatening obstetric condition characterized by abnormal placental adherence or invasion into the myometrium. Although it is commonly associated with previous cesarean delivery, PAS may rarely occur following spontaneous mid-trimester abortion in women without a uterine scar. We present two cases of placenta increta diagnosed after spontaneous mid-trimester abortion with retained products of conception and persistent vaginal bleeding. Both patients underwent transvaginal ultrasonography with colour Doppler followed by pelvic magnetic resonance imaging (MRI), which confirmed focal myometrial invasion. The first patient, a 31-year-old multiparous woman who desired future fertility, was managed conservatively with systemic methotrexate, serial serum beta-human chorionic gonadotropin (β-hCG) monitoring, and close ultrasonographic follow-up, resulting in complete resolution of retained placental tissue. The second patient, a 43-year-old multiparous woman with completed family and severe anemia underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy after preoperative optimization with blood transfusion and had an uneventful postoperative recovery. These cases highlight that PAS should be considered in women presenting with persistent bleeding after spontaneous abortion, particularly when highly vascular retained products are identified on imaging. Early diagnosis using ultrasonography and MRI facilitates timely individualized management. Conservative treatment may be successful in carefully selected women desiring fertility preservation, whereas hysterectomy remains the definitive treatment in women with completed family or significant risk of hemorrhage.